General Surgery at Northpointe

Available Forms

Colonoscopy Screening Form General Surgery at Northpointe History and Physical General Surgery at Northpointe Patient Registration Form Miralax and Dulcolax Bowel Prep for Colonoscopy

General Surgery at Northpointe History and Physical

Patient Name *

Patient *

New

Established

Please choose one.

Primary Care Physician *

Please submit first and last name

Referring Physician *

Please submit first and last name.

Chief Complaint *

New Patient History

Describe your main problem? *

Where is your problem located? *

How severe is your problem? *

How long have you had this problem *

What other things happen with this problem?

Have you ever had any of the following? *

Please mark all that apply.

Hospital *

Please list Hospitalizations/Surgeries/Serious Injuries.

Allergies *

Please list medications you are allergic to and reactions.

Current Medication List *

Please list current medication list.

Patient Social History

Marital Status

Single

Married

Separated

Divorced

Widowed

Use of Alcohol *

Never

Rarely

Moderate

Daily

Use of Tobacco *

Never

Previously-but quit

Current packs/day

Use of Drugs *

Never

Type/Frequency

Family Medical History

Father

Age, Diseases, if Deceased, Cause of Death

Mother

Age, Diseases, if Deceased, Cause of Death

Siblings

Age, Diseases, if Deceased, Cause of Death

Spouse

Age, Diseases, if Deceased, Cause of Death

Children

Ages, Diseases, if Deceased, Cause of Death

Constitutional

Good general health lately *

Yes

Recent weight change *

Yes

Fever *

Yes

Fatigue *

Yes

Eyes

Eye disease or injury *

Yes

Glasses/Contact lens *

Yes

Blurred or double vision/Glaucoma *

Yes

ENT

Hearing Loss *

Yes

Sinus Problems *

Yes

Nose bleeds *

Yes

Bad breathe or bad taste *

Yes

Sore throat or voice change *

Yes

Swollen glands in neck *

Yes

Cardiovascular

Heart Attack *

Yes

Chest Pain *

Yes

Sudden heart beat changes/Arrhythmia *

Yes

Respiratory

Frequent coughing *

Yes

Spitting up blood *

Yes

Shortness of breath *

Yes

Asthma or wheezing *

Yes

Gastrointestinal

Loss of appetite *

Yes

Change in bowel movement *

Yes

Nausea or Vomiting *

Yes

Frequent diarrhea *

Yes

Painful bowel movements or constipation *

Yes

Blood in stool *

Yes

Genitoutinary

Frequent urination *

Yes

Burning or pain urination *

Yes

Blood in urine *

Yes

Incontinence or dribbling *

Yes

Kidney Stones *

Yes

Male-testicle pain

Yes

If applicable

Female

Number of pregnancies and miscarriages if applicable.

Musculoskeletal

Joint pain *

Yes

Joint stiffness or swelling *

Yes

Weakness of muscles *

Yes

Muscle pain or cramps *

Yes

Back Pain *

Yes

Cold extremities *

Yes

Restless Legs *

Yes

Skin

Rash or itching *

Yes

Change in skin color *

Yes

Chronic sores in legs *

Yes

Breast lump *

Yes

Breast discharge *

Yes

Breast pain *

Yes

Varicose veins *

Yes

Neurological

Frequent or recurring headaches *

Yes

Light headed or dizzy *

Yes

Seizures *

Yes

Numbness or tingling sensations *

Yes

Tremors *

Yes

Paralysis *

Yes

Stroke *

Yes

Head Injury *

Yes

Psychiatric

Memory loss or confusion *

Yes

Nervousness *

Yes

Depression *

Yes

Sleep problems *

Yes

Endocrine

Glandular or hormone problem *

Yes

Thyroid disease *

Yes

Diabetes *

Yes

Hematologic/Lymphatic

Slow to heal after cuts *

Yes

Easily bruise or bleed *

Yes

Anemia *

Yes

Past transfusion *

Yes

HIV or Hepatitis *

Yes

Phlebitis *

Yes

Patient Signature

To be provided at the time of services.

Physician Signature

To be provided at the time of services.

* Required field